Upstate providers navigate challenges during Medicaid reform effort

ALBANY — Upstate health care providers starting to navigate New York’s Medicaid waiver program are finding ways to mitigate the bumps along the way, five months into the second year of the $7.3 billion Delivery System Reform Incentive Payment (DSRIP) program.

The program channels money to provider networks with the goal of reducing hospitalizations.

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In New York City and Long Island, those teams of hospitals that have paired with health care providers, community-based providers and long-term facilities — or Performing Provider Systems — are relatively close, and in areas in which public transportation is readily available. But in upstate regions, PPSs face the difficulty of serving Medicaid patients through multiple counties, and of spanning urban pockets as well as rural areas.

Aside from the vast geographical coverage areas, upstate PPSs also face the challenge of serving Medicaid populations that are generally older, suffer from chronic illnesses and face a shortage in health care providers.

To make sure that quality of care remains consistent throughout its eight-county area, which includes the urban city of Buffalo, Millennium Collaborative Care breaks down its PPS into three regions — Northern, Central and Southern Tier — to hone in on each one’s specific needs.

Care Compass Network — which covers Delaware, Chenango, Broome, Tioga, Cortland, Tompkins, Schuyler, Chemung and Steuben counties — also breaks its PPS into regions so it can tailor coverage to their specific needs, according to its interim executive director Robin Kinslow-Evans, who is also the vice president of strategic planning at United Health Services.

For a PPS like Catholic Medical Partners, which mainly covers Buffalo and its surrounding suburbs, telemedicine is becoming an integral part of coverage. Roughly a quarter of patients served under the PPS are in Chautauqua and Niagara counties, said its president and CEO Dennis Horrigan. And in some of the more rural communities, patients may have complications accessing specialists.

State Medicaid director Jason Helgerson said the way to ensure the ultimate goal of DSRIP — to reduce avoidable hospitalizations by 25 percent over the next five years — is to allow PPSs around the state to tailor their initiatives to meet specific geographical needs.

”What we attempted to do was to weigh against those desires for standardization against the fact that we wanted the providers in this community to be able to tailor the initiative and pick projects consistent with community needs, understanding that the community needs in the Adirondacks are going to be different than the community needs in the Bronx,” Helgerson told POLITICO New York.

For such PPSs, the distance — along with the lack of public transportation in rural communities — has proven to be an issue in efforts to mitigate hospitalization.

Assemblywoman Addie Russell, who represents the North Country and was part of a committee to redesign health systems there, said transportation creates an access barrier for people trying to get health care.

“The problem is that you have the distance barrier. So that creates an access barrier, which oftentimes leads to people going without care for longer periods of time and being sicker without getting the attention that they need. And that ultimately is far more costly than insuring that people have access,” she said.

Hammond said Millennium Collaborative Care faced a similar challenge.

“One of the primary barriers to the Medicaid population to getting good health care and primary care is transportation. So one of the things we do in an urban environment in Erie County is we can utilize public transportation venues to make sure people get the healthcare they need,” he said. “In the rural areas, we have to get a little more creative with transportation based on the infrastructure.”

And for a PPS like the Alliance for Better Health Care, which serves Montgomery and Fulton counties, investing in a fleet of vehicles is crucial to ensuring that patients get to their appointments and meeting the goal of reducing hospitalizations, said St. Mary's Healthcare president and CEO Vic Giulianelli.

Another obstacle such upstate PPSs have found is that the communities they serve are typically older and have more chronic illnesses that may require hospitalization if not treated properly.

"We probably serve the oldest market in New York state — another challenge, because the older patients use more services, because there are more comorbidities they live with," Giulianelli said. "A lot of chronic conditions, and lots of complications that come with that."

And there's also a health care provider shortage in upstate New York.

"In rural areas in upstate New York you find a similar phenomenon, which is you have an aging health care workforce. And it’s difficult to fill some of those, because the younger generation gravitates toward where they went to school or urban areas where — not only for them, but for a spouse — there is more job opportunities and hence a potential for higher income,“ Helgerson said.

Those challenges come amid high stakes for the state.

If upstate Medicaid patients keep relying on hospitals for their primary care, the PPSs won't meet their goals of reducing hospitalization. That in turn will reduce the funding — hundreds of millions of dollars — they get from the federal government and frustrate the state's prospects of successfully redesigning Medicaid.

But there are bright spots in the early phases of the DSRIP rollout.

There are fewer PPSs upstate than downstate, and some of the providers have already collaborated in the past.

"Yes, geography and how spread out the population is creates challenges. But I think the upstate folks have some advantages that the folks in the downstate region don't have, and that really is that there are fewer PPSs," Helgerson said. "[They] have a long history of collaboration that other people don't have."

Russell, who represents the region where Fort Drum is located, attested to that.

"Our hospitals have had to work together, and Medicare health care systems have had to work together to scale up to serve the Fort Drum population, so we have more of a well-oiled machine in place," she said.

"it’s a lot easier to have one set of projects implemented across the setting," Helgerson said. "You have one discussion going on. Everyone is pulling in the same direction. It’s much more difficult and complex when you have multiple PPSs."